Colitis and Crohn's Foundation (India) consensus statements on use of 5-aminosalicylic acid in inflammatory bowel disease.

Despite several recent advances in therapy in inflammatory bowel disease (IBD), 5-aminosalicylic acid (5-ASA) therapy has retained its place especially in ulcerative colitis. This consensus on 5-ASA is obtained through a modified Delphi process, and includes guiding statements and recommendations based on literature evidence (randomized trials, and observational studies), clinical practice, and expert opinion on use of 5-ASA in IBD by Indian gastroenterologists. The aim is to aid practitioners in selecting appropriate treatment strategies and facilitate optimal use of 5-ASA in patients with IBD.

Indian guidelines on imaging of the small intestine in Crohn's disease: A joint Indian Society of Gastroenterology and Indian Radiology and Imaging Association consensus statement.

The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients suspected to have or having Crohn's disease. The 29 consensus statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.

Diet and inflammatory bowel disease: The Asian Working Group guidelines.

INTRODUCTION: These Asian Working Group guidelines on diet in inflammatory bowel disease (IBD) present a multidisciplinary focus on clinical nutrition in IBD in Asian countries. METHODOLOGY: The guidelines are based on evidence from existing published literature; however, if objective data were lacking or inconclusive, expert opinion was considered. The conclusions and 38 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required. RESULTS: Diet has an important role in IBD pathogenesis, and an increase in the incidence of IBD in Asian countries has paralleled changes in the dietary patterns. The present consensus endeavors to address the following topics in relation to IBD: (i) role of diet in the pathogenesis; (ii) diet as a therapy; (iii) malnutrition and nutritional assessment of the patients; (iv) dietary recommendations; (v) nutritional rehabilitation; and (vi) nutrition in special situations like surgery, pregnancy, and lactation. CONCLUSIONS: Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 38 recommendations.

Correction to: Diet and inflammatory bowel disease: The Asian Working Group guidelines.

The recommendations 31 which recommend "VSL#3®", refer only to the product used in the cited literature and equivalent products independent from the present product labelings. This product is now known by the generic name "De Simone Formulation".

Imaging of the small intestine in Crohn's disease: Joint position statement of the Indian Society of Gastroenterology and Indian Radiological and Imaging Association.

The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients with suspected or known Crohn's disease. These 29 position statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.

A comparative evaluation of scoring systems for assessing necro-inflammatory activity and fibrosis in liver biopsies of patients with chronic viral hepatitis.

INTRODUCTION: To compare the five scoring systems in assessing grading and staging of liver biopsies from patients with chronic viral hepatitis and their problems and pitfalls. MATERIALS AND METHODS: Liver biopsies from 25 patients with chronic viral hepatitis were studied. Sections were stained with Haematoxylin and Eosin, Reticulin and Masson's Trichrome stains. Van Gieson, Perl's and Shikata's Orcein stains were used as and when required. Coded histological sections were scored independently by three histopathologists using the Knodell Histology Activity Index (HAI), the Scheuer scoring system, Ishak's system, Metavir system and Ishak modified HAI. RESULTS: There were 15 males and 10 females. Their mean age was 51.24 years. On histological examination, hepatocytes showed degenerative changes with varying grades of necrosis (spotty and confluent). Widening of portal tracts with varying severity of mononuclear inflammatory infiltrate and interface hepatitis was observed. Fibrosis appeared as periportal, portal-portal and portal-central septa. A significant agreement was found by kappa statistics for both grading (p< 0.001) as well as staging (p < 0.001) among all the five scoring systems. Lobular activity was the only parameter that showed some discrepancy. No significant intra observer difference was observed. CONCLUSION: It is concluded that all the scoring systems are equally good for grading and staging in the hands of an experienced hepatopathologists.

Association of helicobacter pylori infection with type 2 diabetes.

INTRODUCTION: Helicobacter pylori (H. pylori) infection has been associated with increased levels of inflammatory cytokines and subsequent insulin resistance and epidemiologically linked to type 2 diabetes. OBJECTIVES: To study the prevalence rate of H. pylori infection in type 2 diabetes and its relation with HbA1C levels. MATERIALS AND METHODS: In this cross-sectional case-control study, 80 patients (≥18 years) who met the Americans with Disabilities Act (ADA) criteria for diabetes were recruited. Similarly, 60 age, sex, and education matched healthy controls were taken. They were tested for H. pylori infection by rapid urease test, histological examination of antral endoscopic biopsy specimens and serology. The relationship between H. pylori infection and levels of plasma glucose and HbA1C was assessed. RESULTS: Out of the 80 patients of type 2 diabetes, H. pylori infection was found in 62 (77.5%) while it was present in only 35 (58.3%) of 60 controls, which was found to be significant (Chi-square test: 5.919, df = 1, P value = 0.015). Mean HbA1C among diabetics with H. pylori infection was 8.19 ± 1.16% and without H. pylori infection was 6.9 ± 0.84% (t = 4.3872, P value = 0.0001). CONCLUSIONS: Prevalence of H. pylori infection was significantly higher in diabetes as compared to controls. Presence of H. pylori infection significantly correlated with the level of HbA1C.

Colon tumors and colonoscopy.

A large number of abstracts dealing with colonoscopy were presented at Digestive Disease Week (DDW; 7-10 May 2011; Chicago, Illinois, USA). Topics included: new techniques in colonoscopy, recent innovations in endoscopic ultrasonography (EUS), prevention of postpolypectomy bleeding, Raman spectroscopy, bowel preparation during colonoscopy, risk factors for high grade dysplasia (HGD) in colonic adenoma, recent advances in endoscopic treatment of colorectal cancer (CRC), and follow-up of HGD and CRC after endoscopic treatment. This review focuses on the most relevant presentations dealing with colon tumours and colonoscopy.

Clinical profile, genotype and management updates of hepatitis B virus.

Hepatitis B virus (HBV) is a well known agent of acute and chronic hepatitis, liver cirrhosis and hepatocellular carcinoma. Around 400 million people worldwide carrier of HBV of which more than 250 million reside in Asia, and 1-2 million people have died from it. It has a partially double-stranded DNA, having 3.2-kb genome size and replicate via reverse transcription of RNA intermediate. In the natural history or during the antiviral therapy of chronic HBV infection, seroconversion from HBeAg to anti-HBeAg is usually accompanied by a decrease in viral replication and remission of liver disease. Based on genomic sequence data HBV is classified into eight genotypes A-H and four major serotypes ayw, ayr, adw and adr on the basis of complete genome and S gene sequence analysis. Genotypes and serotypes are useful tools in understanding the epidemiology of HBV infection. HBV genotypes have distinct geographical distributions. The HBV variants appear during HBeAg seroconversion and they bring mutations in the precore region (PC) that prevent HBeAg synthesis. Another common HBeAg variant is the basal core promoter mutant (BCP) characterized by point mutation in the promoter of both HBeAg mRNA and core protein mRNA. The most frequent core promoter mutation is the double A1762T and G1764A nucleotide exchange, which results in a substantial decrease in HBeAg expression but enhanced viral genome replication. The approved antiviral drugs such as Interferon, lamivudine, adefovir dipivoxil, entecavir and telbivudine for purpose of treating chronic HBV infection is to prevent or stop the progression of liver injury by suppressing viral replication or eliminating infection. Sustained losses of viral markers of active viral replication (HBeAg and HBV DNA) are the standard end point of the therapies.

Helicobacter pylori and gastric cancer.

Helicobacter pylori has been the subject of intense investigation since its culture from a gastric biopsy in 1982. From the beginning, this gram-negative bacterium has provoked the interest of bacteriologists, gastroenterologists, infectious disease specialists, cancer biologists, epidemiologists, pathologists, and pharmaceutical scientists. Pathologists were among the first groups of scientists to reevaluate their data in the context of the newly discovered bacterial etiological agent. Chronic inflammation elicited by the bacterium provided the missing link in the progression to gastric carcinoma; accordingly, H. pylori was named as a class 1 carcinogen by the World Health Organization. Two key papers published in 1991 in the Journal of the National Cancer Institute reported a positive association between gastric cancer and H. pylori infection. This fact provided a strong rationale to treat all who tested positive for H. pylori. Antibiotic regimens have been largely successful, but some agents such as metronidazole and clarithromycin have been rendered ineffective in several countries and geographical areas of the United States by the emergence of strains resistant to these compounds. Although there was some skepticism initially, within few years numerous research groups verified the association of H.pylori with gastric carcinoma. Host related factors for the development of disease can indicate genetic susceptibility (or resistance) or acquired influences, which may stimulate defenses of the host against environmental carcinogens like H.pylori. The present article is a mini-review of the history and epidemiology of the bacterium and its suggested association with the development and progression of gastric cancer.

Microscopic colitis in patients presenting with chronic diarrhea.

AIM: To investigate the prevalence of microscopic colitis among patients presenting with chronic watery diarrhea. MATERIAL AND METHODS: Colonic biopsies from 400 patients presenting with chronic watery diarrhea and other symptoms pertaining to lower gastrointestinal tract were studied. After a detailed clinical history and thorough physical examination full length colonoscopy was done using flexible colonoscope. Colonic biopsies were taken from abnormal and normal areas. Three to five micron thick sections were cut and stained with hematoxylin and eosin and Masson's trichrome stain to highlight sub epithelial collagen. RESULTS: Fifteen out of 400 (3.7%) colonic biopsies from patients presenting with chronic diarrhea had evidence of microscopic colitis. Five out of fifteen biopsies (33%) were diagnosed as collagenous colitis, 10 biopsies (67%) had evidence of lymphocytic colitis; 14/400(3.5%) histologically normal biopsies were taken as controls to compare various demographic and risk factors. Ten out of 15 patients (67%) were clinically diagnosed as irritable bowel syndrome. In the remaining five an infective etiology was suspected. On colonoscopy12/15 (80%) had no abnormality and 3/15 (20%) had mild hyperemia. CONCLUSION: A possibility of microscopic colitis should be considered while examining colonoscopic biopsy of a patient with chronic watery diarrhea and normal colonoscopy to avoid the misdiagnosis that may affect the treatment of patients.

Effects of postural changes and removal of vestibular inputs on blood flow to and from the hindlimb of conscious felines.

Considerable data show that the vestibular system contributes to blood pressure regulation. Prior studies reported that lesions that eliminate inputs from the inner ears attenuate the vasoconstriction that ordinarily occurs in the hindlimbs of conscious cats during head-up rotations. These data led to the hypothesis that labyrinthine-deficient animals would experience considerable lower body blood pooling during head-up postural alterations. The present study tested this hypothesis by comparing blood flow though the femoral artery and vein of conscious cats during 20-60 degrees head-up tilts from the prone position before and after removal of vestibular inputs. In vestibular-intact animals, venous return from the hindlimb dropped considerably at the onset of head-up tilts and, at 5 s after the initiation of 60 degrees rotations, was 66% lower than when the animals were prone. However, after the animals were maintained in the head-up position for another 15 s, venous return was just 33% lower than before the tilt commenced. At the same time point, arterial inflow to the limb had decreased 32% from baseline, such that the decrease in blood flow out of the limb due to the force of gravity was precisely matched by a reduction in blood reaching the limb. After vestibular lesions, the decline in femoral artery blood flow that ordinarily occurs during head-up tilts was attenuated, such that more blood flowed into the leg. Contrary to expectations, in most animals, venous return was facilitated, such that no more blood accumulated in the hindlimb than when labyrinthine signals were present. These data show that peripheral blood pooling is unlikely to account for the fluctuations in blood pressure that can occur during postural changes of animals lacking inputs from the inner ear. Instead, alterations in total peripheral resistance following vestibular dysfunction could affect the regulation of blood pressure.

Management of chronic hepatitis B virus infection: a promising approach using small interfering RNA (siRNA).

Hepatitis B virus infection continues to be a major global health problem with an estimated 350 million carriers. The response to available treatment modalities is not impressive. The advent of RNA Interference--a phenomenon of sequence-specific degradation of RNAs mediated by double-stranded RNA--holds promise as a potential therapy for chronic hepatitis B virus infection. Synthetic preparations of short RNA (21-23 bp long) can be used to mediate this process of gene silencing with a lower immune response. The duration of suppression can be further increased by using a vector delivery system. Small interfering RNA (siRNA) has several advantages over conventional therapy, which include fewer side-effects, a lower chance of developing escape mutants and non-requirement of viral replication for its action. A potent knockdown of the gene of interest with high sequence specificity makes RNA interference a powerful tool that has shown antiviral effect against hepatitis B virus. However, the 'off-target effect', i.e. suppression of genes other than the intended target, poor siRNA stability, inefficient cellular uptake, widespread biodistribution and non-specific effects need to be overcome. The problem of long-term toxicity of siRNA should be addressed and an ideal vector delivery system needs to be designed before it can be put to clinical use.

Large-diameter balloon dilation after endoscopic sphincterotomy for removal of difficult bile duct stones.

BACKGROUND AND STUDY AIMS: Endoscopic sphincterotomy followed by extraction using a Dormia basket or an extraction balloon catheter is the procedure that is generally used for the removal of bile duct stones. This is not successful in all patients, however, and some stones have to be extracted using lithotripsy devices. In an attempt to avoid mechanical lithotripsy, we used large-diameter balloons after sphincterotomy for removing stones that could not be extracted using the conventional methods. PATIENTS AND METHODS: In this retrospective pilot study, large-diameter (15-mm, 18-mm, or 20-mm maximum sizes) balloon dilation of the sphincterotomy site was performed in 50 patients in whom bile duct stones could not be removed by endoscopic sphincterotomy and Dormia basket or balloon catheter extraction. RESULTS: The stones varied in size from < 15 mm to 25 mm. Common bile duct stones could be removed in all the patients using the large-diameter balloon technique. A Dormia basket or an extraction balloon catheter was required for removal of stones in 29 patients (58 %); and mechanical lithotripsy was required in five patients (10 %). Minor oozing of blood was seen in 16 patients (32 %), but the ooze stopped spontaneously during the endoscopy. Melena occurred in two patients and major bleeding requiring surgery occurred in one patient. Mild acute pancreatitis that resolved with conservative management occurred in four patients (8 %). There were no perforations and no deaths. CONCLUSIONS: Large-diameter balloon dilation of the sphincterotomy site is an effective procedure for removal of bile duct stones that cannot be extracted by endoscopic sphincterotomy and conventional extraction devices. Mechanical lithotripsy could be avoided in the majority of these patients using this approach.

Role of intravenously administered hyoscine butyl bromide in retrograde terminal ileoscopy: a randomized, double-blinded, placebo-controlled trial.

AIM: To evaluated the role of hyoscine butyl bromide in facilitating retrograde ileoscopy. METHODS: Retrograde terminal ileoscopy was attempted in 200 consecutive patients undergoing colonoscopy. After intubation of the cecum and visualization of the ileocecal valve, butyl bromide injection or normal saline was given intravenously to the patients in a double blind random fashion. The pulse rate and oxygen saturation were measured continuously. After completion of the procedure, endoscopists were then asked to score the ease of intubation and the ease of visualization of the terminal ileum on a visual scale of 1 to 10. The patients were also asked to score the pain after receiving hyoscine butyl bromide injection on a score of 1 to 10. RESULTS: Terminal ileoscopy could be performed in 188 patients. The mean (SD) visual analogue score for the ease of intubation of the cecum was 7.4 (0.65) in the injection group and 5.9 (0.8) in the placebo group (P < 0.001). The mean (SD) length of ileum visualized in the injection group was 14.4 (3.3) cm and 10.4 (2.7) cm in the placebo group (P < 0.001). The mean (SD) visual analogue score for ease of visualization of the terminal ileum was 7.5 (0.69) in the injection group and 5.9 (0.7) in the placebo group (P < 0.001). The pain score experienced by the patients was 6.5 (0.7) in the injection group and 6.7 (0.69) in the placebo group (P < 0.008). Although the pulse rate increased significantly in patients receiving the drug, no statistically significant difference was noted in the oxygen saturation between the two groups either before or after administration of the drug. No complications were observed in either of the groups. CONCLUSION: Hyoscine butyl bromide injection is a useful adjunct in helping the intubation and visualization of terminal ileum during colonoscopy.

Ileoscopy in patients with ileocolonic tuberculosis.

AIM: To study the role of retrograde terminal ileoscopy in patients suspected to have ileocolonic tuberculosis. METHODS: A retrospective analysis was performed for patients undergoing colonoscopy for suspected ileocolonic tuberculosis between January 2000 and June 2004, in whom retrograde ileoscopy had been performed. Only patients diagnosed with tuberculosis on the basis of histological findings of either a caseating granuloma or those having non-caseating granuloma or a collection of epithelioid cells at a minimum of one endoscopic lesion (either in the colon or the terminal ileum) on histology with good responses to conventional anti-tuberculous drugs were enrolled for the study. RESULTS: Fifty-three patients were included. The terminal ileum was involved in only 11 patients. Eight of these patients had involvement of the cecum too. Two patients had ileal lesions without cecal involvement; however, lesions were noted in the ascending colon. In one patient the whole colon was normal and only the terminal ileum showed nodularity and ulceration. Histological examination of the ileal biopsies obtained from the ileal lesions showed noncaseating granulomas in five, collection of epithelioid cells in four and nonspecific histology in two patients. Mucosal biopsies obtained from the lesion in the terminal ileum, in the patient in whom mucosal abnormality was observed to be confined to the ileum, showed noncaseating granulomas. In two other patients the ileal biopsies alone showed histological evidence of tuberculosis with biopsies from the colonic lesions showing non-specific inflammatory changes only. CONCLUSION: Retrograde ileoscopy should be performed in all patients undergoing colonoscopy for suspected ileocolonic tuberculosis. In some patients only the terminal ileum may be involved and histological examination may reveal evidence of tuberculosis only from the lesions in the terminal ileum. This approach would lead to additional lesions being picked up and increasing the chances of well-timed diagnosis of tuberculosis.

Is conventional sphincterotomy possible in patients with common bile duct stones impacted at the ampulla of Vater?

BACKGROUND: Needle knife precut papillotomy has been used to gain access or remove impacted common bile duct stones at the ampulla of Vater. However, precut papillotomy is a risky procedure with high complication rates and is presumably best dealt with by the expert. We attempted to find out the feasibility of performing conventional endoscopic sphincterotomy in patients with impacted stones at the ampulla. METHODS: All patients undergoing endoscopic retrograde cholangiopancreatography for stones impacted at the ampulla between the years 2000 and 2005 were enrolled in the study. All attempts were made to achieve biliary cannulation through the conventional route including use of the long route or guidewire to cannulate the papilla. Needle knife papillotomy was resorted to only if attempts to cannulate the papilla through the conventional route failed. The success and complications of the procedures were recorded. RESULTS: Thirty-two patients were enrolled. The impacted bile duct stone could be removed in all the patients. Conventional endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were performed in 23 patients with impacted stones. The long route had to be employed in seven patients while guidewire cannulation of the papilla was needed in four patients. Needle knife papillotomy was needed in only nine patients. None of the patients in whom the conventional route was employed developed complications, whereas bleed requiring endoscopic management was observed in three (33%) of the nine patients in whom needle knife papillotomy was performed. CONCLUSIONS: Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy can be performed by the conventional route in the majority of patients with impacted stones at the ampulla. This approach appears to be safer than needle knife papillotomy. However, needle knife papillotomy may be required in patients in whom biliary access cannot be gained through the conventional approach.